Pneumopathies extra-hospitalières liées aux soins (un concept pertinent ?)

Il est proposé de classer les pneumonies en Pneumonies Aiguës Communautaires (PAC), Pneumonies Extra-Hospitalières Liées aux Soins (PEHLS), Pneumonies Acquises à l Hôpital (PAH) et Pneumonies Acquises sous Ventilation Mécanique (PAVM), afin, notamment, de proposer une antibiothérapie initiale mieux adaptée. Cependant les données concernant les PEHLS et les PAH sont peu nombreuses, notamment en France. Il s agit d une étude épidémiologique, rétrospective, monocentrique. Nous avons recueilli les données épidémiologiques, cliniques, biologiques, microbiologiques, et thérapeutiques de toutes les pneumopathies infectieuses admises dans notre unité de Réanimation entre janvier 2006 et avril 2008. Sur les 263 patients inclus, 86 avaient une PAC (33%), 57 une PEHLS (21%), 89 une PAH (34%) et 31 une PAVM (12%). La gravité à l admission de ces différentes pneumonies était identique selon l Index de Gravité Simplifié (IGS2), ainsi que le taux de mortalité. Lors des PEHLS, les prélèvements ont mis en évidence 35,1% de bactéries communautaires et 28,8% de bactéries hospitalières . Aucune documentation bactériologique n a pu être faite dans 47,4% des cas. Lors des PAH, des germes communautaires ont été mis en évidence dans 18,9% des cas et des germes hospitaliers dans 58,4% des cas. Aucune documentation bactériologique n a pu être faite dans 33,7%. Dans notre expérience, nous ne pouvons pas proposer d utiliser la classification des pneumonies en PEHLS, concept trop hétérogène, ne permettant pas à lui seul de proposer une attitude thérapeutique adéquate.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

: Todd’s paralysis: a neurologic pitfall to be aware of

International audienceLa paralysie de Todd est définie par une crise comitiale partielle suivie par un déficit neurologique temporaire. Ce déficit, partiel ou complet, est généralement unilatéral et dure entre 30 minutes et plusieurs jours avant résolution complète. Une paralysie de Todd peut aussi se présenter comme un trouble phasique ou un trouble visuel, avec le même caractère temporaire. Il est important de connaître l’existence de ce syndrome pour le distinguer d’un accident vasculaire cérébral accompagné de manifestations épileptiques, car l’approche thérapeutique est évidemment bien différente. Nous rapportons un cas didactique de paralysie de Todd, survenu chez une femme de 77 ans

Link between non hypoxemic chronic obstructive pulmonary disease and executive functioning in oldest old

International audienceBackground. COPD (chronic obstructive pulmonary disease) may result in cognitive disorders (mainly executive) even without hypoxemia. Methods. The aim of this descriptive study was to highlight a deficit in task-switching in non-hypoxemic patient with COPD and mild cognitive impairment (MCI) or Alzheimer disease (AD). The main judgment criterion was patients' performances on the TMTA and B. COPD patients were recruited via the database (CogDisCo) of the geriatric medicine department at Pitie Salpetriere hospital in Paris. Results. 7 patients had Alzheimer's disease (AD), and 11 mild cognitive impairment (MCI): they were matched for age, sex, MMSE, education level with controls subjects without COPD. There was no significant difference between the two groups. However, patients with COPD and MCI required, on average, an extra 13 seconds compared with patient without COPD for the TMTA and 18 seconds for the TMTB. Patients with COPD and AD needed, on average, an extra 63 seconds for TMTA and 97 seconds for TMTB. The number of errors for the TMTB was the same in the both groups. Conclusion. This preliminary study does not show statistically significant results but the time for achieving TMT was longer in the population with COPD whether AD or MCI. These results encourage us to continue with prospective studies on larger samples

Biomarkers of vascular dysfunction and cognitive decline in patients with Alzheimer’s disease: no evidence for association in elderly subjects

International audienceBackgroundSeveral studies have suggested that vascular dysfunction plays an important role in Alzheimer’s disease.AimsWe hypothesized that significant differences might be observed in the levels of blood endothelial biomarkers across elderly population of subjects with dementia.MethodsWe analyzed, in a prospective monocentric study, three different endothelial biomarkers, endothelial microparticles (EMPs), endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs) in 132 older patients who underwent a full evaluation of a memory complaint.ResultsThere was no difference in specific EMP, EPC or CEC levels between demented or non-demented patients, nor considering cognitive decline.DiscussionBlood endothelial biomarkers may be too sensitive and it is likely that the multimorbidity observed in our patients may lead to opposite and confounding effects on endothelial biomarkers levels.ConclusionUnlike younger AD patients, our results suggest that endothelial biomarkers are not valuable for the diagnosis of dementia in elderly patient

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture

International audiencePerioperative myocardial infarction remains a frequent and life-threatening complication in noncardiac surgery.[1–3] In 2012, redefinition of acute myocardial infarction highlighted the importance of troponin elevation in association with either electrocardiographic changes, and/or clinical symptoms of ischemia, and/or new wall motion anomalies.[4] However, large database analyses have recently extended the concept of perioperative myocardial infarction to myocardial injury after noncardiac surgery because even subtle and isolated increase in troponin irrespective of ischemic features (i.e., ischemic symptoms and electrocardiogram [ECG] findings) is associated with a significant mortality risk.[5,6] This result is in agreement with previous studies showing that isolated troponin rise (ITR) is associated with an increased mortality risk in various nonischemic conditions such as sepsis,[7] pulmonary embolism,[8] renal failure,[9] and acute respiratory failure in chronic obstructive pulmonary disease patient.[10

Exposure to psychotropics in the French older population living with dementia: a nationwide population-based study

International audienceBackgroundLittle is known about the level of psychotropic chronic exposure in all patients living with dementia. The aim of the study was to quantify chronic psychotropic exposure in older adults with dementia compared with the general population of the same age. MethodsThis prospective cohort study was conducted in France between 2009 and 2011. Aged at least 65years, 10,781,812 individuals (440,215 of them with dementia) either community based or nursing home residents were included. The numbers of single or combined prescriptions, per year for antipsychotics, antidepressants, anxiolytics, or hypnotics were measured. ResultsOf patients with dementia, 15.5% are exposed to antipsychotics compared with 2.2% of the age-matched population (relative risk [RR]=6.44, 95% confidence interval [CI] [6.39-6.48]), 39.5% to antidepressants compared with 12.6% (RR=4.10, 95% CI [.4.07-4.12]), and 39.6% to anxiolytics or hypnotics compared with 26.9% (RR=1.74, 95% CI [1.72-1.75]). Among older adults with dementia, 13.8% simultaneously consumed at least three psychotropics. All class age of older patients with dementia is more exposed to all psychotropics except for long-acting benzodiazepines. During the study period, chronic anxiolytic/hypnotic and antipsychotic exposure slightly decreased in population with dementia while chronic exposure to antidepressant drugs tended to increase. ConclusionThis nationwide, population-based, drug-used study showed for the first time that older patients with dementia are chronically overexposed not only to antipsychotics but also to psychotropics

Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions

BackgroundOrgan dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions.MethodsThis was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer–Lemeshow test).ResultsFour hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71–0.81) and the Hosmer–Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1.ConclusionsIn a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.</p

Factors influencing plasma transfusion practices in paediatric intensive care units around the world

Background and Objectives Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to >5% of their patients, whereas another 25% transfused plasma to <1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. Materials and Methods Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients’ case‐mix in each unit, unit's characteristics, and local blood product transfusion policies and processes. Results The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case‐mix, centre characteristics or local transfusion services were not identified as significant relevant factors. Conclusion Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research